Provider Demographics
NPI:1336232958
Name:SOUTHERN PAIN INSTITUTE, PC
Entity Type:Organization
Organization Name:SOUTHERN PAIN INSTITUTE, PC
Other - Org Name:SOUTHERN PAIN & DIAGNOSTICS INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:THADDEUS
Authorized Official - Last Name:CLAVO
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-632-3730
Mailing Address - Street 1:1975 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4794
Mailing Address - Country:US
Mailing Address - Phone:770-632-3730
Mailing Address - Fax:770-632-3731
Practice Address - Street 1:1975 HIGHWAY 54 W
Practice Address - Street 2:SUITE 100
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4794
Practice Address - Country:US
Practice Address - Phone:770-632-3730
Practice Address - Fax:770-632-3731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045425208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG72848Medicare UPIN
GAGRP6066Medicare ID - Type Unspecified